Grace Brethren Village

In the surveyor’s words

From the most serious findings on record at Grace Brethren Village, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 13, 2025

  Based on record review, interviews, and policy review, the facility failed to prevent a resident from falling out of bed. This resulted in Actual Harm when Resident #11 fell out of bed and was transferred to the hospital where she was found to have a thoracic (section of the spine between the neck and end of ribs) compression fracture. This affected one (Resident #11) out of three residents reviewed for falls. The facility census was 38. Findings include: Review of the medical record for Resident #11 revealed an admitted [DATE]. […]

• No harm, potential for more than minimal, widespreadF880Dec 7, 2023

  Based on record review, observations, staff interviews, review of guidelines from Centers for Disease Control and Prevention (CDC) and policy review, the facility failed to implement infection control policies and guidelines to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This had the potential to affect all 37 residents residing in the facility. Facility census was 37. Findings include: 1. Observation on 12/06/23 at 9:54 A.M. revealed State tested Nursing Assistant (STNA) #10 was outside of Resident #34's room. Resident #34's door was noted to have a sign taped to it for droplet precautions and a three-drawer cart just outside the door. STNA #10 was observed wearing a surgical mask and no eye protection. […]

• No harm, potential for more than minimal, widespreadF812Mar 31, 2022

  Based on observations, staff interviews,and policy review, the facility failed to safely store food in the dry storage, refrigerator, freezer and failed to sanitize kitchen equipment. This affected 31 of 31 residents who receive food from the kitchen, excluding Resident #6 who does not eat food from the kitchen. The facility census was 32. Findings include Observation on 03/28/22 from 9:20 to 9:30 A.M., with Dietary Manager (DM) #88 revealed noodles in dry storage were tied but were undated. Four large cans of cream corn had large fist sized dents and had been placed on the shelf for use. A large bag of cauliflower had a baseball sized hole and was left open to air with piece falling out of the bag. A bag of frozen chicken was undated and had been freezer burnt. […]

• No harm, potential for more than minimal, patternF689Jan 30, 2025

  Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure residents had adequate supervision and use of appropriate assistive devices to prevent falls. This affected three (Residents #4, #11, and #21) of five residents reviewed for falls. The facility also failed to thoroughly investigate resident falls and implement interventions to prevent further falls. This affected one (Resident #34) of five residents reviewed for falls. The facility census was 39 residents. Findings include: 1.Review of the medical record for Resident #4 revealed an admitted [DATE] with diagnoses including Parkinson's disease, vascular dementia, psychosis and anxiety. […]

• No harm, potential for more than minimal, isolatedF760Aug 27, 2026

  Based on medical record review, staff interview, and review of an online medication information resource, the facility failed to ensure a resident received the correct medication and total doses. This affected one (#1) of five residents reviewed for unnecessary medications. The census was 33. Findings include:Review of Resident #1's medical record revealed an admission date of 07/16/26. Diagnoses included breast cancer, osteoarthritis, type two diabetes mellitus, and hip replacement.Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition.Review of post-surgery orders dated 07/15/26 revealed Resident #1 was ordered cefadroxil (antibiotic) 500 milligrams (mg) oral twice a day for 10 days, 20 capsules total.Review of physician orders… […]